Downloaded 10/04/21 01:29 PM UTC History of Contremoulins’ Stereotaxis Tives

HISTORICAL VIGNETTE J Neurosurg 127:1426–1435, 2017 The first formulation of image-based stereotactic principles: the forgotten work of Gaston Contremoulins Cole A. Giller, MD, PhD, MBA,1 Patrick Mornet, MD, AIHP,2 and Jean-François Moreau, MD, AIHP, FACR3 1Neurosurgery Department, Augusta University, Augusta, Georgia; 2La Rochelle, France; and 3Université & Faculté de Médecine Paris Descartes, PRES Sorbonne-Paris Cité, Paris, France Although image-based human stereotaxis began with Spiegel and Wycis in 1947, the major principles of radiographic stereotaxis were formulated 50 years earlier by the French scientific photographer Gaston Contremoulins. In 1897, frus- trated by the high morbidity of bullet extraction from the brain, the Parisian surgeon Charles Rémy asked Contremoulins to devise a method for bullet localization using the then new technology of x-rays. In doing so, Contremoulins conceived of many of the modern principles of stereotaxis, including the use of a reference frame, radiopaque fiducials for registra- tion, images to locate the target in relation to the frame, phantom devices to locate the target in relation to the fiducial marks, and the use of an adjustable pointer to guide the surgical approach. Contremoulins’ ideas did not emerge from science or medicine, but instead were inspired by his training in the fine arts. Had he been a physician instead of an artist, he might have never discovered his extraordinary methods. Contremoulins’ “compass” and its variants enjoyed great success during World War I, but were abandoned by 1920 for simpler methods. Although Contremoulins was one of the most eminent radiographers in France, he was not a physician, and his personality was uncompromising. By 1940, both he and his methods were forgotten. It was not until 1988 that he was rediscovered by Moreau while reviewing the history of French radiology, and chronicled by Mornet in his extensive biography. The authors examine Contremoulins’ stereotactic methods in historical context, describe the details of his devices, relate his discoveries to his training in the fine arts, and discuss how his prescient formulation of stereotaxis was forgotten for more than half a century. https://thejns.org/doi/abs/10.3171/2016.10.JNS161966 KEY WORDS stereotaxis; history of medicine; stereotactic surgery; gunshot wounds; art and science; radiology T is widely accepted that the first image-based human he is only rarely mentioned in the English language.2,4,37 In stereotactic procedure was performed in 1947 by Spie- 1988 his work was accidentally rediscovered,65,67 but even gel and Wycis,92 based on concepts pioneered by Hors- several years later he was only briefly mentioned in the Iley and Clarke.45 It is less well known that the first device historical literature.63,72 incorporating stereotactic principles with x-rays was in- We describe the stereotactic method of Contremou- vented 50 years earlier by the French photographer Gaston lins, its origins from techniques of art, and its similarity Contremoulins and successfully used in humans to local- to modern stereotaxis. We discuss how stereotactic ideas ize and extract intracranial bullets early in 1897.67,68,83 His invented late in the 19th century to locate foreign objects methods, developed only 16 months following the discov- became forgotten before the reinvention of stereotaxis 50 ery of x-rays,86 included most of the elements of modern years later. stereotaxy and, remarkably, were inspired by techniques used by artists for sculpture and drawing. Gaston Contremoulins: Early Years and Although Contremoulins became one of the most emi- Training nent radiographers in France, his methods were forgotten Contremoulins was born in Rouen, France, in 1869. His by 1940, and he himself slipped into obscurity.67,74 Many father was a respected locksmith, and his grandfather was historical accounts omit him completely, 27,32, 46,77,89,93, 97,98 and a skilled mechanic who serviced some of the first locomo- SUBMITTED July 27, 2016. ACCEPTED October 13, 2016. INCLUDE WHEN CITING Published online February 17, 2017; DOI: 10.3171/2016.10.JNS161966. 1426 J Neurosurg Volume 127 • December 2017 ©AANS, 2017 Unauthenticated | Downloaded 10/04/21 01:29 PM UTC History of Contremoulins’ stereotaxis tives. The family tradition of precision mechanical work had a profound influence, enabling him to later build the radiological devices for which he became famous (Fig. 1).67 Contremoulins was neither a physician nor a physicist, but instead was a gifted artist trained at the School of Fine Arts (École des Beaux-Arts) in Rouen, where he studied drawing and sculpture for 3 years. The school exposed him to viewpoints and provided training that would later inspire his scientific activities: a mildly rebellious attitude toward conventional art,23 an appreciation of the new field of photography,75 and a set of technical artistic skills. After leaving the École, his attempt to earn a living as an artist in Paris was so unsuccessful that he was forced to use the heat from hallway lanterns to cook his meals.67 His artistic talents would have to wait until he could find other employment. Attachment to Étienne-Jules Marey FIG. 1. Contremoulins in his workshop, in which his devices were fabri- cated. Contremoulins is in the foreground.67 Copyright owned by Patrick At that time, Étienne-Jules Marey was one of the most Mornet (coauthor). celebrated physicians in Paris.91,95 Like Contremoulins, he valued precision mechanical work, inventing a sphygmo- 99 graph to record the pulse waveform and a “photographic the nature and properties of the x-rays.” At first, x-ray de- gun” that could acquire 12 images each second. Inspired vices were freely available. Customers in stores could view images of their own bones for a small fee, and x-rays were by the work of Muybridge, Marey studied the motion of 48,67 animals and humans, including a famous recording of a used in parlors to stage glowing occult séances. With- cat landing on its feet.91 He was a member of the presti- out the restrictions that would come later, Contremoulins gious Académie de Médecine, and became president of was free to explore this new technology that piqued his both the Académie de Sciences and the Institut de France interest as a photographer. When a laboratory for the study in 1895. of the effects of x-rays was established under direction of the surgeon/histologist Charles Rémy in Paris, Contre- Driven by his interest in photography and his need 67 for employment, Contremoulins became a technician in moulins quickly became its préparateur. He and Rémy the microphotography laboratory of the Paris Faculty of began a long and fruitful collaboration, exploring x-ray Medicine under the direction of Mathias Duval in 1890. studies of organs, the use of angiography in cadavers, and Duval’s secondary appointment as a professor of anatomy the localization of foreign objects and contributing many 79–81,83 at the École Nationale des Beaux-Arts of Paris26,31 likely innovations in radiographic technology. added to the profound influence that the arts would have upon Contremoulins. The Treatment of Gunshot Wounds to the Contremoulins’ talents were quickly recognized. He Head in the 19th Century was chosen by Marey in 1894 to work as his préparateur, participating in Marey’s studies of locomotion and devel- Treatment of gunshot wounds in the early 19th century included poultices of bread and milk, with surgery oping some of the technology that made the studies pos- 30 sible.56,65,67,80,81 Marey was also a painter and sculptor, be- deferred unless needed for hemostasis. But by the mid- lieving that “science and art meet in the search for truth.”67 1800s, Gross listed the extraction of bullets as one of the 5 principles for the treatment of gunshot wounds, and His movies of flying birds were known both for their value 38 to the field of aviation and as works of art, and the painter observed that “the best probe…is the finger.” In 1873, Marcel Duchamp was inspired to create his famous “Nude Erichsen stated that bullets “cannot be allowed to remain Descending a Staircase, No. 2” by Marey’s movies of lo- lodged in the body with impunity” and that military sur- 12,48 geons agreed that “Bullets should always be extracted if comotion. Despite a 40-year difference in age, Contre- 33 moulins and Marey seemed to be kindred spirits, shar- they can be found.” However, he advised against deep ing an artistic appreciation of nature for years that would exploration of gunshot wounds to the head. By 1893, Keen advocated aggressive bullet extraction from the head in later become pivotal. Contremoulins would draw upon the 47 techniques of fine arts to develop his stereotactic methods, An American Textbook of Surgery. For deep-seated and Marey would repeatedly use his considerable influ- fragments, he recommended passing a probe through the ence to support the career of his younger colleague.67 brain along the bullet track to the opposite side of the skull, where a trephination was performed. Silk strands and catheters were passed between the wounds to guide The Advent of Radiography passage of a forceps through the brain to grab the bullet. Three years after Marey and Contremoulins began A preoccupation with bullet extraction is also evident their collaboration, Wilhelm Roentgen announced his in historical accounts. Physicians caring for Abraham discovery of x-rays,86 and soon after that “a little army of Lincoln after his fatal gunshot wound explored his brain workers [was] busy in all parts of the world, investigating with their fingers to search for the bullet and evacuate any J Neurosurg Volume 127 • December 2017 1427 Unauthenticated | Downloaded 10/04/21 01:29 PM UTC C.

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